Provider Demographics
NPI:1164552295
Name:REDA, CHARLES JOHN JR (ATC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOHN
Last Name:REDA
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9511 59TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9680
Mailing Address - Country:US
Mailing Address - Phone:941-727-3556
Mailing Address - Fax:
Practice Address - Street 1:9511 59TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-9680
Practice Address - Country:US
Practice Address - Phone:941-727-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL3822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer